Louie Johnston
14 Oct 2021 · Coroner Graeme Irvine · East London
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. inadequate CTG monitoring visibility
“CTG trace monitoring equipment that was in use in the labour ward required staff to switch from a CTG trace screen to a K2 electronic recording screen during delivery. This meant that a graphic representation of the CTG trace was not clearly visible at all times. Instead , midwifery staff were required to crouch down and record numeric data from the CTG displayed on a small LED screen. The Trust identified this as counter-productive and raised the issue with the manufacturer of the system. To date”
2. inadequate staff CTG training compliance
“A review of staff training records indicated that an obstetric registrar involved in the delivery was not up to date with mandated annual CTG training. Additionally, the obstetric consultant had not completed annual training which required the session to be repeated following the death of [the deceased]. Systems in place at the Trust did not ensure that all medical staff had completed requisite training .”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“Poor technical quality of the CTG readings at a crucial time especially given "this was the first trace in am emergency situation”
This report
“CTG trace monitoring equipment that was in use in the labour ward required staff to switch from a CTG trace screen to a K2 electronic recording screen during delivery.”
Responses
No published response was found on judiciary.uk.